Chapter Two. Accumulation syndrome and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that stimulate the intestines, promote bowel movement in order to purge accumulation, eliminate toxic substances, drain fire and cold of the body and drive out congested water. They are used to treat excess conditions and interior syndromes. These methods and strategies relieve the symptoms rather than treat the cause. However, they can stop further pathological changes caused by the accumulations.
Although accumulations can result from several pathogenic factors, such as food, phlegm, water and blood, in this chapter only accumulation of the intestines and accumulation of water are discussed. Accumulations of food, phlegm and blood are discussed in other chapters.
Obstruction of the intestines, intestinal adhesions and intussusception are acute abdominal syndromes and they have severe pathological consequences. They cause accumulation of feces, Qi, blood, heat and fire-toxin in the intestines. As well as regular western medical treatment, certain intestinal ad-hesions, intussusception and the primary stage of simple or partial intestinal obstruction can be treated with Chinese herbal medicine.
Fire-toxin, as a pathological product as well as a pathogenic factor, can accumulate in the intestines. Fire-toxin should be eliminated as soon as possible, especially before long-term accumulation and when the blood is not strongly disturbed, in order to prevent further development of disease, such as in chronic mild infections of the intestines, or at the primary stage of acute appendicitis, acute pancreatitis, acute cholecystitis, hepatitis and ulcer perforation and inflammation.
The action of downward-draining herbs can move the bowels, thus eliminating toxins from the body when Liver and Kidney functions are impaired and they fail to remove toxic substances, such as in cirrhosis of the Liver and renal failure. If a toxic substance has been ingested, the action of downward-draining herbs can assist the body in eliminating it.
When water metabolism is disturbed, water can accumulate in certain places, such as the hydrothorax and ascites, which can obstruct the Qi. In acute and excess conditions, they should be drained downwards by herbs with a cathartic effect in order to relieve symptoms.
CAUTIONS AND CONTRAINDICATIONS
1. Protect the Stomach and body fluids:
To treat severe accumulation, the purgative herbs in the formula are strong and their speed is fast, thus they easily injure Stomach-Qi and body fluids. Compared with other moist laxatives, these herbs should only be used for a short period and their dosage should be controlled carefully. Long-term usage of purgatives for constipation may lead to consumption of the body fluids in the intestines and make constipation worse. As soon as the purgative action takes effect and the symptoms are less severe, the formula should be discontinued.
2. Use only in excess conditions:
Since the actions of the strong purgative formula are harsh, they are only used for excess syndromes and for people with a strong constitution. For patients who suffer from deficiency syndromes but who also need these herbs in the treatment of acute or severe accumulation, such as in weak, elderly people and people with a chronic disease, tonifying herbs must be used as well.
3. Avoid usage in menstruation, bleeding conditions and in pregnancy:
Formulas that strongly drain downward can also drain Qi as well as blood downward, so they are not suitable for use during heavy menstruation or in bleeding conditions. They should not be used in pregnancy.
4. Unsuitable in exterior syndrome:
Formulas that drain downwards are, in principle, not suitable for patients who have an exterior syndrome. It is better to treat the exterior syndrome first and not to drain downwards, otherwise it can lead to the exogenous factors entering into a deeper region of the body.
5. Caution in special cases:
When downward-draining formulas are used to treat acute abdominal syndromes, such as acute intestinal obstruction, appendicitis, cholecystitis and pancreatitis, it is also important to remember that these herbs are only suitable for certain periods in the whole pathological process of the disease, or certain types of disorder. These formulas should only be prescribed by doctors after modern medical examination. If herbal treatment does not result in relief of symptoms, western medical treatment is usually indicated.
6. Appropriate diet:
During treatment, patients should take care of their diet. Soft, warm, light and easily digested food is recommended.
1. Accumulation syndrome due to excess heat in the intestine
Manifestations
Main symptoms in a severe case
Severe constipation, dry stool (sometimes a foul-smelling fluid is excreted instead of stool), flatulence, bowel movement once in several days, severe focal abdominal pain increased on pressure, a tense and firm abdomen. There may be tidal fever, delirious speech and profuse sweating.
Tongue
Red or deep-red with a yellow or brown, dry, thick coating.
Pulse
Rapid, deep, forceful.
Main symptoms in a moderate case
Constipation or habitual constipation, dry stool, irregular bowel movement, distending pain of the abdomen.
Tongue
Slightly red or deep-red with a sticky, white or yellow coating.
Pulse
Wiry, slippery.
Secondary symptoms
Fullness in the chest and epigastria, thirst, reduced appetite and irritability.
Associated disorders in western medicine
Constipation, habitual constipation, uremia, acute intestinal obstruction, acute abdominal conditions.
Analysis of the syndrome
This syndrome is caused by accumulation in the intestines. The accumulation generates heat and this further injures the fluid of the intestines and makes the accumulation worse. The Qi is obstructed by the accumulation, which causes fullness, distension and pain in the abdomen. The conditions of the heat and body fluids are shown in the degree of constipation.
In severe cases:
• the heat is so strong that the patient may have profuse sweating, thirst and fever
• if heat disturbs the mind, patients may be irritable and speech may be delirious
• the tongue coating is very dry and the color of the coating changes from yellow to brown, indicating increasing heat. A deep-red tongue with red spots also indicates heat. A thick tongue coating and a forceful and slippery pulse are signs of the accumulation.
In a moderate case of constipation:
• the feces are dry or are difficult to defecate, and bowel movement occurs only once every 2 or 3 days. The primary cause is dryness in the intestines with heat and Qi stagnation. This is usually caused by reluctance to go to the toilet, and this develops habitual constipation, such as is seen in primary school pupils and adults with a busy life. It can be seen in people with a Yang type of constitution, or people who eat lots of fried or spicy food that produces heat. People who take too little physical exercise may have Qi stagnation that leads to constipation. Furthermore, deficiency of Qi, blood, Yin and Yang may lead to Qi stagnation and dryness in the intestines. In this case, although feces are not very dry, bowel movement is very slow and difficult.
(See Figure 2.1 on page 69.)
Treatment principle: Drain the heat in the Large Intestine and move the stool; promote Qi movement and nourish the body fluids
Note
In a severe condition, promoting bowel movement is a quick and effective way to purge accumulation, drain the heat, protect the fluid in the intestines and relieve pain and distension due to Qi stagnation. In a moderate case of constipation or in a case of chronic habitual constipation, moistening the intestines, increasing the fluid and activating the Qi are more important than clearing heat and purging the stagnation.
Herb selection principles and formula composition strategies
• In a severe case of constipation, herbs that are cold and salty or cold and bitter, and that can enter the Large Intestine meridian, purge the intestines and move stool are selected.
• In a moderate or mild case of constipation, the first priority is to select herbs that are seeds and rich in oils, can moisten the intestines and move stool.
• Herbs that are sweet and cold, and nourish the Yin and fluids of the Stomach and Large Intestine in order to moisten the intestines and soften stool are selected.
• Herbs that activate Qi movement in the Stomach, Large Intestine and Liver are selected.
• Herbs that regulate the blood, clear heat, remove phlegm, soothe the Stomach-Qi and tonify the weakness of Qi, blood, Yin or Yang can be added if these disorders are present.
• In a chronic condition, herbs that protect the Spleen and Stomach and can moderate the function of the purging herbs are selected.
• Herbs that enter the Lung and disperse the Lung-Qi so as to accelerate the Large Intestine-Qi to descend can be added.
Structure of the formula and selection of herbs
Chief: Stimulate the intestines and purge the stool in a severe case; moisten the intestines and promote bowel movement in a moderate case
Da Huang ( Rhei rhizoma)
Da Huang is a very bitter and cold herb. As it purges the intestines intensively, it can strongly drain heat and move the stool. It is the most important herb to treat excess heat accumulation in the intestines. Da Huang can be prescribed as chief in a formula in a severe case.
Da Huang is a very good purgative agent compared with such agents in western medicine. It stimulates the intestines and purges the bowels without severe cramp. The purgative effect appears 6–8 hours after oral consumption of this herb; as an enema, it has a much quicker onset of action.
Da Huang can be used raw or processed. Raw Da Huang has a stronger function of purging the accumulations in the intestines than baked Da Huang. Raw Da Huang should not be cooked for too long, otherwise the purgative action becomes weaker.
Mang Xiao ( Natrii sulfas)
Mang Xiao is another commonly used purgative substance. It is salty and cold, can moisten the intestines, soften the feces and therefore promote bowel movement. It is particularly suitable for constipation when the feces are very dry.
The main constituent of Mang Xiao is sodium sulfate. As the intestines cannot absorb sulfate, it stays in the intestines and increases osmotic pressure to accumulate water in the intestines, stimulate them and soften the feces.
Several products of Mang Xiao can be selected. The commonly used version is called Mang Xiao. Another version, called Pu Xiao, contains salt, calcium sulfate and magnesium sulfate as well as sodium sulfate. Its ability to promote bowel movement is stronger.
Da Huang and Mang Xiao are often used together to treat constipation and excess heat in the intestines. Because Da Huang can purge the bowels and Mang Xiao can soften the feces, their therapeutic actions are accentuated.
Lu Hui ( Aloe folii extractus)
Lu Hui is very bitter and cold, and enters the Liver, Heart, Stomach and Large Intestine meridians. It is a very strong herb to purge the bowels and reduce excess heat. It directly drains Liver-fire and Heart-fire. It is selected when the heat of Heart and Liver affects the Stomach and Large Intestine.
Fan Xie Ye ( Sennae folium)
Fan Xie Ye is sweet, bitter and cold, and enters the Large Intestine meridian. It has a moistening nature and is able to moisten dryness in the intestines, clear heat and promote bowel movement. Its function of moving the bowels is stronger than that of Da Huang. If a small dosage of Fan Xie Ye is applied, it can also promote digestion and is used for constipation caused by improper diet.
Huo Ma Ren ( Cannabis semen) and Yu Li Ren ( Pruni semen)
These two types of seed contain oils and can moisten the intestines. In addition, they have a descending ability and can promote Qi movement. Thus they are often selected in formulas to treat mild or chronic constipation. They are often used for habitual constipation.
Huo Ma Ren is a sweet and neutral herb, and it can either promote bowel movement or tonify the Qi and blood. It is particularly suitable for treating constipation after surgical operations or delivery of a baby, and in patients who suffer from chronic diseases or have a weak constitution. It can also be used to treat hemorrhoids and habitual constipation.
Yu Li Ren is pungent, bitter, sweet and neutral, and enters the Spleen, Small Intestine and Large Intestine meridians. It is moist in nature and has a descending tendency of action. It is able to descend the Qi, promote bowel movement and urination and is usually used in excess syndromes.
These two herbs are often used together to treat chronic constipation as this accentuates their therapeutic actions.
Deputy: Nourish the Yin and moisten the Stomach and Large Intestine
Mai Men Dong ( Ophiopogonis radix), Xuan Shen ( Scrophulariae radix) and Sheng Di Huang ( Rehmanniae radix)
These herbs are cold in temperature and all three can nourish the Yin and clear heat in the intestines. As such, they are often used as deputies in a formula to treat constipation due to dryness and heat in the intestines. They can be used together or separately according to the degree of dryness and heat in the Large Intestine.
Zhi Shi ( Aurantii fructus immaturus) and Hou Po ( Magnoliae cortex)
These two herbs are often used as assistants to promote Qi movement and descend the Qi in the Large Intestine so as to assist the chief herb to move the stool.
Zhi Shi is bitter and cold, and can strongly direct the Qi downwards in the Large Intestine. It is an important herb to break up the stasis of Qi, phlegm and food.
Hou Po is bitter and warm, and can effectively descend the Qi in the Lung, Stomach and intestines to reduce fullness, dry dampness and eliminate phlegm.
These two herbs are often used together to treat severe cases and chronic moderate cases of constipation as this can accentuate their therapeutic actions.
Bing Lang ( Arecae semen), Mu Xiang ( Aucklandiae radix)**, Lai Fu Zi ( Raphani semen) and Gua Lou Ren ( Trichosanthis semen)
These four herbs all enter the Large Intestine meridian. In formulas for promoting bowel movement, they can effectively promote Qi movement so as to assist the purgative function of the chief herbs. They can be selected separately or in groups.
Bing Lang is pungent, bitter and warm, and is good at promoting Qi movement and reducing the accumulation of food. It is only used in severe distension of the abdomen due to accumulation of food and dampness.
Mu Xiang is aromatic, pungent, bitter and warm, and has a drying nature. It can effectively move the Qi and reduce pain due to Qi stagnation. As it also enters the Liver meridian, it is particularly suitable for use in conditions where the Liver-Qi attacks the Spleen, Stomach and Large Intestine.
Lai Fu Zi is pungent, sweet and neutral, and enters the Spleen and Stomach meridians. Its function in the formula is to promote digestion and reduce fullness.
Gua Lou Ren is sweet and cold, and enters the Lung, Stomach and Large Intestine meridians. As a seed, it can directly moisten the intestines and move the stool. Since it enters the Lung meridian, it can eliminate phlegm and descend the Qi, which can accelerate the downward movement of the Qi in the intestines and promote bowel movement. It is usually used in cases of chronic constipation.
Xing Ren is a seed and has the function of moistening the Large Intestine and promoting bowel movement. It enters the Lung meridian, which is externally/internally related to the Large Intestine meridian, and is used especially to treat disturbance of the dispersing and descending function of the Lung-Qi that influences the intestines and causes constipation. It can also be used as a strategic assistant to disperse the Lung-Qi so as to activate the Qi in the intestines.
Jie Geng is a strategic assistant in the formula. As it enters the Lung meridian and has an ascending property, it ascends the Qi in the Lung in order to accelerate the Qi descending in the Large Intestine. In this way, it assists herbs that purge and drain downwards and herbs that descend Qi in the intestines. For applying this strategy, Jie Geng should be used in small dosage.
Lian Qiao ( Forsythiae fructus) and Shi Gao ( Gypsum)
In the condition of constipation due to excess heat in the intestines, it is important to reduce the heat without delay because heat consumes fluid in the intestines and leads to constipation.
Lian Qiao is aromatic, bitter and cold, and has a dispersing and opening-up ability. It can disperse and clear heat from accumulation in the intestines.
Shi Gao is pungent, sweet and cold. It can effectively clear heat from Yang Ming meridians. As it is sweet and cold, and can generate the body fluids, it is particularly suitable for conditions where the body fluids are being constantly injured by heat.
Huang Jing ( Polygonati rhizoma), Dang Gui ( Angelicae sinensis radix) and Rou Cong Rong ( Cistanchis herba)**
These herbs can tonify the Qi, blood and Yang respectively. They are all moist in nature. They can be applied in chronic constipation that is caused by deficiency of Qi, blood and Yang respectively.
Assistant and envoy: Protect the Stomach and Spleen, and moderate the function of the purging herbs
Zhi Gan Cao ( Glycyrrhizae radix preparata) and Feng Mi ( Mel)
Zhi Gan Cao is sweet and enters the Spleen meridian. In formulas that drain downwards, it is often used as corrective assistant and envoy to protect the Stomach from harsh herbs such as Da Huang and Lu Hui. It can also moderate the function of the herbs in the formulas and make the purgative action lasting and stable.
Feng Mi has a similar function to Zhi Gan Cao in protecting the Spleen and Stomach and in moderating the speed of harsh herbs. Furthermore, it is moistening in nature, can tonify the Spleen, moisten the intestines and promote bowel movement.
Examples of classical formulas
Da Cheng Qi Tang (Major Order the Qi Decoction) 
Source: Shang Han Lun 
Composition
Da Huang ( Rhei rhizoma) 12 g
Mang Xiao ( Natrii sulfas) 9 g
Zhi Shi ( Aurantii fructus immaturus) 12 g
Hou Po ( Magnoliae cortex) 15 g
Analysis of the formula
This formula is able to vigorously purge heat accumulation and promote bowel movement. It is used in a condition of severe obstruction of feces, Qi, blood and fire-toxin in the abdomen. The manifestations are severe constipation, distension, pain and fullness of the abdomen, which are increased by pressure. It also treats a condition of severe constipation where dry feces have accumulated in the intestines and a foul-smelling fluid is excreted instead of stool. The patient has a red tongue with a dry, thick, yellow coating and a wiry or tight, and rapid pulse.
In this formula:
• The chief herb is Da Huang. It is bitter and cold, can vigorously stimulate the intestines, purge the heat accumulation and move the stool. With the salty and cold Mang Xiao as deputy, which can increase the fluid of the intestines and soften the stool, the function of purging the stool is increased.
• Zhi Shi and Hou Po serve as assistants. They can activate the Qi movement in the intestines and the Lung so as to accelerate the purgative function of the chief and deputy herbs. They can also directly reduce the fullness of the abdomen.
When the four herbs are used together, the heat accumulation is removed and the Stomach-Qi can descend properly. This function is described in the name of the formula, a formula that vigorously orders the (Large Intestine) Qi.
Commentary on strategies
There are several strategies shown in the formula.
• Da Huang is used as chief in a reasonably large dosage. It is added at the last moment when the decoction is prepared, and therefore its purgative action is intensive and strong.
• One side effect of the purgative action of Da Huang is cramp of the abdomen. Herbs that soften the stool and activate the Qi movement in the intestines can reduce this unpleasant sensation. In this way, the dosage of Da Huang can also be reduced.
• The four herbs in the formula all work on promoting bowel movement; however, they work via different approaches and enhance each others’ effects. Although it is a small formula, its action is very strong and effective.
The following strategies are employed when using this formula:
• If a bowel movement occurs, this formula should not be used again.
• If the purgative effect has not appeared after 6–8 hours, the same formula should be given again. If there is still no reaction, another dose should be given in a shorter time interval.
• If the patient has a bowel movement, but the accumulation is not completely eliminated, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) – a formula with a milder function of purging the accumulation – should be applied instead of this strong formula.
Xiao Cheng Qi Tang (Minor Order the Qi Decoction) 
Source: Shang Han Lun 
Composition
Da Huang ( Rhei rhizoma) 12 g
Hou Po ( Magnoliae cortex) 6 g
Zhi Shi ( Aurantii fructus immaturus) 9 g
Analysis of the formula and commentary on strategies
Xiao in Chinese means little and gentle. Xiao Cheng Qi Tang is a formula that can gently purge accumulated heat and move the bowel. It is used for treating a moderate obstruction of heat and Qi in the Large Intestine, or in a condition after using Da Cheng Qi Tang (Major Order the Qi Decoction) if the accumulation has not been eliminated completely. The symptoms and signs are moderate compared to those of Da Cheng Qi Tang. Patients may suffer from tidal fever, constipation and abdominal fullness and pain, which are not increased by pressure. The tongue is red with a yellow, dry coating and the pulse is slippery and rapid.
Comparing this formula with Da Cheng Qi Tang, Mang Xiao is not used as the dryness in the Large Intestine is not as severe. The dosages of Zhi Shi and Hou Po are also reduced as the Qi obstruction is less severe than that in the former case. As the three herbs are cooked together, the purgative action is more gentle than that of the former formula.
The change of combination, the change of dosage and the preparation method show that the strategies take account of the condition of the individual at that moment as well as the pathological change of the disorder.
Tiao Wei Cheng Qi Tang (Regulate the Stomach and Order the Qi Decoction) 
Source: Shang Han Lun 
Composition
Da Huang ( Rhei rhizoma) 12 g
Mang Xiao ( Natrii sulfas) 12 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 6 g
Analysis of the formula and commentary on strategies
Compared with Da Cheng Qi Tang (Major Order the Qi Decoction), this formula is able to promote bowel movement and purge the clumped heat in a steady and moderate way. In addition, the constipation is not as severe as in the syndrome of Da Cheng Qi Tang, and the fullness due to the stagnation of Qi is less. Patients suffer from constipation, fullness of the abdomen and poor appetite. At the same time, they may have thirst, fever and irritation. The tongue coating is sticky and yellow and the pulse is slippery and rapid.
Huang Long Tang (Yellow Dragon Decoction) 
Source: Shang Han Liu Shu 
Composition
Da Huang ( Rhei rhizoma) 12 g
Mang Xiao ( Natrii sulfas) 9 g
Zhi Shi ( Aurantii fructus immaturus) 9 g
Hou Po ( Magnoliae cortex) 12 g
Ren Shen ( Ginseng radix) 6
Gan Cao ( Glycyrrhizae radix) 3 g
Dang Gui ( Angelicae sinensis radix) 9 g
Sheng Jiang ( Zingiberis rhizoma recens) 3 pieces
Da Zao ( Jujubae fructus) 2 pieces
Jie Geng ( Platycodi radix) 3 g
The dosages have been added as there were no dosages in the original book.
Analysis of the formula
This formula is able to drain heat, promote bowel movement and tonify Qi and blood. It is used to treat deficiency of Qi and blood with severe constipation due to excess heat in the Large Intestine. The weakness shows in the weak pulse, fatigue and shortness of breath.
In this formula:
• The first four herbs are the same as in Da Cheng Qi Tang (Major Order the Qi Decoction). However, they are in smaller dosages and Da Huang is cooked together with the other herbs, thereby reducing its harsh purgative action.
• Ren Shen and Gan Cao are used to tonify the Qi, and Dang Gui and Da Zao to tonify the blood. They are used as deputies in the formula.
• Gan Cao, Sheng Jiang and Da Zao are also used as assistants to protect the Stomach and Spleen from the purgative herbs.
• Jie Geng is used as strategic assistant with a low dosage. It can ascend the Lung-Qi in order to accelerate the Qi descending in the Stomach and Large Intestine.
Commentary on strategies
This formula demonstrates a principle for treating a complicated case.
• When Qi and blood are too weak to activate Qi movement in the intestines in order to move the stool, it is better to use some tonifying herbs to assist the purgative herbs. Otherwise, not only may the accumulation of heat and stool increase rapidly in the intestines, but these pathogenic products may also further injure the Qi and blood.
• The second interesting strategy in this formula is the use of Jie Geng to open up the Lung-Qi in order to accelerate the Qi descending in the Large Intestine as the Lung and the Large Intestine are related.
The combination of these strategies results in an effective therapeutic outcome in the treatment of this severe and complicated condition.
Zeng Ye Cheng Qi Tang (Increase the Fluid and Order the Qi Decoction) 
Source: Wen Bing Tiao Bian 
Composition
Xuan Shen ( Scrophulariae radix) 30 g
Mai Men Dong ( Ophiopogonis radix) 25 g
Sheng Di Huang ( Rehmanniae radix) 25 g
Da Huang ( Rhei rhizoma) 9 g
Mang Xiao ( Natrii sulfas) 5 g
Analysis of the formula
This formula is able to nourish the Yin, increase the fluid in the Large Intestine, clear the heat there and promote bowel movement. It is used to treat constipation where the fluid in the intestines is extensively consumed by excess heat. It is particularly useful for chronic conditions or after febrile diseases.
Commentary on strategies
In this formula, two groups of herbs are selected to treat two aspects of the syndrome – Yin deficiency and constipation. Furthermore, the side effects of the purgative herbs have to be considered as the Yin and fluid in the intestines may be further injured and constipation can get worse.
• In the first group, a large dosage of salty and cold Xuan Shen is used to nourish the Yin, increase the fluid, clear heat in the Large Intestine and soften the feces. The large dosages of Mai Men Dong and Sheng Di Huang directly nourish the Yin, clear the heat and enhance the ability of Xuan Shen.
• In the second group, Da Huang and Mang Xiao are used to purge the intestines and soften the stool, respectively. They directly treat constipation.
When these two groups are used together, the purgative effect is achieved without injuring the fluid in the intestines.
Ma Zi Ren Wan (Hemp Seed Pill) 
Source: Shang Han Lun 
Composition
Huo Ma Ren ( Cannabis semen) 500 g
Xing Ren ( Armeniacae semen) 250 g
Bai Shao Yao ( Paeoniae radix lactiflora) 250 g
Zhi Shi ( Aurantii fructus immaturus) 250 g
Hou Po ( Magnoliae cortex) 250 g
Da Huang ( Rhei rhizoma) 500 g
Feng Mi ( Mel) is added to the herbal powder to make the pills.
Analysis of the formula
This formula is able to moisten the intestines, drain the heat, promote the Qi movement and move the bowels. It is used for treating constipation due to dryness in the intestines. Patients may suffer from chronic habitual constipation with hard feces that are difficult to defecate, frequent urination, a dry, yellow tongue coating and a deep and rapid pulse.
In this formula:
• Huo Ma Ren serves as chief to moisten the intestines and promote bowel movement.
• The deputies, Xing Ren, Bai Shao Yao and Da Huang, descend the Qi, nourish the Yin and purge the intestines respectively. They help the chief to promote bowel movement using different approaches.
• Zhi Shi and Hou Po can activate the Qi movement in the Large Intestine and are used as assistants to promote bowel movement.
• Feng Mi (honey) is used as assistant. On the one hand, it can directly moisten the Large Intestine and promote bowel movement; on the other hand, it moderates the function of the other herbs and makes the action of stimulating the Large Intestine smoother and last longer. Moreover, it can tonify the Qi of the Middle-Jiao and protect the Spleen and Stomach from injury by purgative herbs. Lastly, it is sweet and viscous, can moderate the tastes of the herbal ingredients and is used as a medium to make pills.
Commentary on strategies
• The strategy of the formula composition is to use seeds, honey and Yin-nourishing herbs to moderate the function of the purgative and Qi-activating herbs.
• Pill is a form of administration to slow down the speed of the action of the herbs and patients will therefore not develop any unpleasant sensations in the abdomen. This form of administration is well suited to treating conditions of chronic constipation.
2. Accumulation syndrome due to excess cold in the Middle-Jiao
Manifestations
Main symptoms
Constipation, abdominal pain and fullness that can be reduced by warmth.
Secondary symptoms
Cold hands and feet, fullness in the hypochondria and epigastrium, reduced appetite and tiredness.
Tongue
White, sticky coating.
Pulse
Deep, wiry and tight.
Associated disorders in western medicine
Food poisoning, constipation, gastric and duodenal ulcer, uremia and acute intestinal obstruction.
Analysis of the syndrome
This syndrome is caused by accumulation of internal cold together with undigested food. It occurs after indulgence in cold food and drinks, which obstruct the Qi of the Stomach and Spleen. It may exist when the Spleen-Yang is deficient; internal cold is thus generated and disturbs the function of the intestines.
• Cold is a Yin pathogenic factor. It has a contracting nature and can easily injure the Yang. When internal cold accumulates in the intestines, the Yang fails to spread warmth and Qi and is unable to transform and transport food, resulting in Qi stagnation. All of these cause constipation, abdominal pain, distension and fullness, reduced appetite, cold limbs and tiredness.
• The symptoms described above can be reduced by warmth and this indicates the presence of cold.
• A white, sticky tongue coating and a deep, wiry, tight pulse also indicate the existence of cold accumulation.
Treatment principle: Warm the Yang and expel cold; promote bowel movement and alleviate pain
Herb selection principles and formula composition strategies
• First, herbs that are hot and pungent, enter the Kidney and Spleen meridians, warm the interior and expel cold are selected.
• Second, herbs that promote bowel movement and eliminate accumulation are selected.
• Third, herbs that activate Qi movement and assist the purging herbs are selected.
• Herbs that tonify Qi, blood, Yin or Yang can be applied if deficiency is present.
• Herbs that protect the Spleen and Stomach, and can moderate the function of purging herbs are used in chronic conditions.
Structure of the formula and selection of herbs
Chief: Warm the interior and expel the cold
Fu Zi ( Aconiti radix lateralis preparata)* and Xi Xin ( Asari herba)*
Fu Zi and Xi Xin are very hot and pungent. They can stimulate the Yang, intensively warm the interior, disperse cold, accelerate Qi movement in the intestines and alleviate pain. They are often used as chief in the formula to treat internal cold syndrome. Since they are poisonous, they should be used with caution.
Gan Jiang ( Zingiberis rhizoma)
Gan Jiang is warm and pungent, and particularly enters the Spleen meridian. It is often used to warm Spleen-Yang to expel the cold in the Middle-Jiao directly, thus accelerating Qi movement in the intestines and alleviating pain. It is particularly used as chief in the formula to treat cold in the Middle-Jiao.
Deputy: Stimulate the Large Intestine and purge the stool
Da Huang ( Rhei rhizoma)
Da Huang is very bitter and cold. It stimulates the intestines intensively and can therefore purge stool. In the formula to treat accumulation in the intestines caused by internal cold, this herb can be used with hot herbs, thus reducing and minimizing the cold nature of Da Huang while still utilizing its function.
Ba Dou ( Crotonis fructus)*
Ba Dou is very hot and poisonous, and enters the Stomach and Large Intestine meridians. It can intensively purge the cold accumulation in the intestines and treat constipation. Because of its toxicity and strong purgative action, it is rarely used in clinical practice as a raw herb. The processed products of Ba Dou are occasionally used in formulas to warm the Middle-Jiao, promote digestion and purge the accumulation in the intestines as its purgative and toxic effects are reduced by processing.
Assistant: Tonify the weakness and protect the Stomach
Ren Shen ( Ginseng radix)
Ren Shen is slightly warm and sweet. It can intensively tonify the Qi in general and improve the body condition. It is used in a syndrome of cold accumulation when the Qi is too weak to stimulate the intestines or the Qi is weakened by frequent use of purgative herbs.
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao is sweet and primarily enters the Spleen meridian. It is able to tonify Spleen-Qi. The more important function of this herb, used as assistant in the formula, is to protect the Stomach from the harsh herbs as well as to smooth and moderate their function.
Ban Xia ( Pinelliae rhizoma) and Sheng Jiang ( Zingiberis rhizoma recens)
Ban Xia and Sheng Jiang are both pungent and warm, and enter the Stomach meridian. They can soothe the Stomach-Qi and eliminate the accumulation of water and phlegm in the Stomach. They relieve nausea and vomiting and improve appetite. All these symptoms are often seen in the syndrome of internal cold in the Middle-Jiao.
Examples of classical formulas
Da Huang Fu Zi Tang (Rhubarb and Prepared Aconite Decoction) 
Source: Jin Kui Yao Lue 
Composition
Da Huang ( Rhei rhizoma) 9 g
Fu Zi ( Aconiti radix lateralis preparata)* 9 g
Xi Xin ( Asari herba)* 3 g
Analysis of the formula
This formula is able to warm the Yang and disperse the cold, promote bowel movement and reduce the accumulation. It is used for treating cold accumulation with undigested food in the intestines. Patients suffer from constipation, abdominal pain and hypochondriac pain, have cold extremities, a white, sticky tongue coating and a wiry, tight pulse.
In this formula:
• The bitter and cold Da Huang and the pungent and hot Fu Zi are used together as chief. Da Huang is used for stimulating the intestines, moving the stool and eliminating the accumulation; Fu Zi is used for warming the Lower- and Middle-Jiao to disperse the cold.
• Xi Xin is used as assistant. It can warm the interior, open up the obstruction of cold and alleviate pain. It enhances the function of Fu Zi.
• In this formula the combined dosages of Fu Zi and Xi Xin are larger than that of Da Huang. They can thus reduce the cold nature of Da Huang but retain its purgative function.
Commentary on strategies
There are only three herbs in the formula, but it has a clear structure and strong function.
• The hot and cold herbs used together can effectively warm the Yang and promote bowel movement.
• The pungent, bitter, warm and cold natures of the herbs used together can disperse and descend the Qi in the intestines.
Wen Pi Tang (Warm the Spleen Decoction) 
Source: Bei Ji Qian Jin Yao Fang 
Composition
Da Huang ( Rhei rhizoma) 12 g
Fu Zi ( Aconiti radix lateralis preparata)* 9 g
Gan Jiang ( Zingiberis rhizoma) 6 g
Ren Shen ( Ginseng radix) 9 g
Gan Cao ( Glycyrrhizae radix) 3 g
Analysis of the formula
This formula is able to warm and strengthen the Spleen-Yang and purge the cold accumulation. It is used for treating cold and dampness accumulation, which injures the blood. Patients suffer from constipation, dysenteric disorders with blood and mucus, and abdominal pain. Cold extremities and a deep and wiry pulse indicate the existence of cold.
In this formula:
• Da Huang and Fu Zi are used as chief for removing the accumulation and warming the interior.
• Gan Jiang serves as deputy; it enhances the function of Fu Zi to warm the Middle-Jiao, the Spleen and the Stomach directly.
• Another deputy is Ren Shen; it can tonify the Qi and strengthen the Spleen.
• Gan Cao is used as assistant to tonify the Middle-Jiao and to protect the Stomach from the harsh herbs. It is also used as envoy to harmonize the herbs in this formula.
Commentary on strategies
Some strategies shown in this formula are compared to Da Huang Fu Zi Tang (Rhubarb and Prepared Aconite Decoction).
• In this formula, the dosage of Da Huang is increased and that of Fu Zi decreased. The tonifying and warming herbs Gan Jiang, Ren Shen and Gan Cao are used instead of the pungent and hot Xi Xin.
• This combination indicates that the purging action is based on a warming and tonifying action. The alterations of herbs in this formula are particularly necessary in chronic and recurrent disorders of cold accumulation in the Middle-Jiao with Spleen-Yang deficiency.
3. Syndrome of water accumulation
Manifestations
Main symptoms
Difficult urination and defecation.
Secondary symptoms
Stifling sensation in the chest, shortness of breath and distension in the abdomen.
Tongue
White, moist coating.
Pulse
Tight, wiry and deep.
Associated disorders in western medicine
Generalized edema, hydrothorax and ascites.
Analysis of the syndrome
This syndrome is caused by accumulation of water in the chest and abdomen. As the accumulation obstructs the Qi in the San Jiao water passage, patients suffer from edema and difficult urination.
• If water accumulates in the chest, patients may feel tightness in the chest and shortness of breath.
• If water accumulates in the abdomen, patients may feel distension in the abdomen.
• The white moist tongue coating indicates the accumulation of water, and the tight and wiry pulse suggests an excess and acute condition. A white tongue coating and a deep pulse also suggest interior cold and deficiency.
Treatment principle: Purge and drive out congested fluid; protect and strengthen the function of the Spleen
Herb selection principles and formula composition strategies
• First, herbs that purge and drive out the congested fluid are selected.
• Second, herbs that tonify the internal organs and promote water metabolism are selected.
• In a chronic condition, herbs that protect the Spleen and Stomach, and can moderate the function of the purging herbs are used.
• After driving out the congested fluid, formulas that strengthen and regulate the functions of Lung, Spleen and Kidney and promote water metabolism should be used.
Structure of the formula and selection of herbs
Chief: Purge and drive out the congested water
Da 
( Knoxiae radix)*, Yuan Hua ( Genkwa flos)* and Gan Sui ( Euphorbiae kansui radix)*
These three herbs are cold in temperature and are poisonous, violently cathartic and diuretic. They can drain water and drive out congested fluid by causing diarrhea and urination. They are used in severe generalized edema or accumulation of fluid in the thoracic or abdominal cavity. According to early studies and experiences, these three herbs are considered incompatible with Gan Cao ( Glycyrrhizae radix).
Although these three herbs are often used together, each has its own characteristics:
• Gan Sui has the strongest cathartic effect and Yuan Hua the weakest.
• Yuan Hua is the most poisonous herb and Gan Sui the least poisonous.
• Gan Sui drives out the fluid from the meridians, Da
from the internal organs and Yuan Hua from the joints and cavities.
from the internal organs and Yuan Hua from the joints and cavities.Shang Lu ( Phytolaccae radix)* and Qian Niu Zi ( Pharbitidis semen)*
Shang Lu is bitter, cold and poisonous, and enters the Lung, Spleen and Kidney meridians. It has a similar but more gentle function than Da 
( Knoxiae radix)*, Yuan Hua ( Genkwa flos)* and Gan Sui ( Euphorbiae kansui radix)*. It is particularly used in the condition of water accumulation in the body.
( Knoxiae radix)*, Yuan Hua ( Genkwa flos)* and Gan Sui ( Euphorbiae kansui radix)*. It is particularly used in the condition of water accumulation in the body.Qian Niu Zi is bitter, cold and poisonous, and enters the Lung, Kidney and Large Intestine meridians. It can purge accumulation from the intestines and treat constipation, as well as drive out water accumulation and treat edema. It can eliminate phlegm and open up the San Jiao meridian. Although less poisonous than Da 
, Yuan Hua and Gan Sui, it is still a very harsh herb.
, Yuan Hua and Gan Sui, it is still a very harsh herb.Deputy: Regulate the Qi
Mu Xiang ( Aucklandiae radix)** and Bing Lang ( Arecae semen)
Mu Xiang is pungent, bitter and warm, and enters the Lung, Liver, Spleen, Stomach and Large Intestine meridians. It is aromatic and drying in nature. It moves both upwards and downwards. It regulates the Qi of the San Jiao, especially the Qi of the Spleen and Stomach. It is an excellent herb for relieving pain caused by Qi stagnation.
Bing Lang is bitter, pungent and warm, and enters the Stomach and Large Intestine meridians. Its pungent and warm nature can stimulate the Qi movement, reduce the accumulation, drain the water and reduce the fullness.
Zhi Shi ( Aurantii fructus immaturus) and Hou Po ( Magnoliae cortex)
These two herbs can be selected together or separately to stimulate the Qi movement and enhance the abilities of the chief herbs.
Zhi Shi is bitter and slightly cold, and enters the Spleen and Stomach meridians. It is quite a strong herb for breaking up the blockage of Qi, food and phlegm, and can reduce the fullness in the abdomen.
Hou Po is bitter, pungent and warm, and enters the Stomach, Spleen, Large Intestine and Lung meridians. Its pungent and warm nature can stimulate the Qi movement, and the bitter and warm nature can dry dampness. It is able to activate the Qi movement in the Upper-, Middle- and Lower-Jiao, reduce the accumulation of phlegm, food and water, and thus very effectively reduce the sensation of fullness.
Assistant: Protect the Stomach and tonify the weakness
Da Zao ( Jujubae fructus)
Da Zao is sweet and warm, and enters the Spleen meridian. It can tonify Qi as well as blood, thus strengthening the foundation of life. In a formula for driving out water, Da Zao is used to tonify the Spleen and protect the Stomach from violent, cathartic and diuretic toxic herbs.
CAUTIONS
Gan Cao ( Glycyrrhizae radix) is incompatible with Da 
( Knoxiae radix)*, Yuan Hua ( Genkwa flos)* and Gan Sui ( Euphorbiae kansui radix)*. It is forbidden to use these herbs together despite Gan Cao being the most commonly used herb to moderate harsh herbs and protect the Spleen.
( Knoxiae radix)*, Yuan Hua ( Genkwa flos)* and Gan Sui ( Euphorbiae kansui radix)*. It is forbidden to use these herbs together despite Gan Cao being the most commonly used herb to moderate harsh herbs and protect the Spleen.Examples of classical formulas
Shi Zao Tang (Ten-Jujube Decoction) 
Source: Shang Han Lun 
Composition
Yuan Hua ( Genkwa flos)* 0.5 g
Da 
( Knoxiae radix)* 0.5 g
( Knoxiae radix)* 0.5 gGan Sui ( Euphorbiae kansui radix)* 0.5 g
Da Zao ( Jujubae fructus) 10 pieces
Analysis of the formula
This formula can drive out the congested fluid in the chest as well as generalized water such as edema.
In this formula:
• Gan Sui, Da
and Yuan Hua are all used as chief herbs. Gan Sui drives out the fluid from the meridians, Da 
from the internal organs and Yuan Hua from the joints and cavities. These three herbs are used together to drive out all of the water accumulation in the body.
and Yuan Hua are all used as chief herbs. Gan Sui drives out the fluid from the meridians, Da from the internal organs and Yuan Hua from the joints and cavities. These three herbs are used together to drive out all of the water accumulation in the body.• Da Zhao is used as assistant to moderate the violent action of the first three herbs.
Commentary on strategies
The strategies are shown in dosage and administration management. They suggest how to deal with poisonous, harsh but useful and necessary herbs.
• The three harsh herbs are added to a decoction of Da Zao, which can tonify the Spleen and protect the Stomach from these violent and poisonous herbs.
• All three herbs are used in a small dosage. Patients with a weak condition must only use half of the dosage.
• The herbs are used only once in the morning. If the condition does not improve, an extra half dosage is used the next day. If diarrhea occurs or the patient is excreting large amounts of urine, the use of the formula should be stopped.
• After using this formula, patients should take easily digested food to strengthen the Stomach and recover its function.
Zhou Che Wan (Vessel and Vehicle Pill) 
Source: Jing Yue Quan Shu 
Composition
Da 
( Knoxiae radix)* 30 g
( Knoxiae radix)* 30 gGan Sui ( Euphorbiae kansui radix)* 30 g
Yuan Hua ( Genkwa flos)* 30 g
Da Huang ( Rhei rhizoma) 60 g
Qian Niu Zi ( Pharbitidis semen)* 120 g
Qing Pi ( Citri reticulatae viride pericarpium) 15 g
Chen Pi ( Citri reticulatae pericarpium) 15 g
Bing Lang ( Arecae semen) 15 g
Mu Xiang ( Aucklandiae radix)** 15 g
Qing Fen ( Calomel)* 3 g
Analysis of the formula
This formula is able to activate Qi movement and promote bowel movement and urination in order to eliminate water accumulation. It treats water accumulation, which will eventually generate heat.
• The chief herbs are Da
, Gan Sui and Yuan Hua. They strongly drive out the congested water.
, Gan Sui and Yuan Hua. They strongly drive out the congested water.• Since the chief herbs are very poisonous and the dosages should be kept to a minimum, a large amount of Qian Niu Zi is added as deputy, along with Da Huang. They enhance the abilities of the chief herbs and ensure the therapeutic result in a safe dosage range.
• Qing Pi, Chen Pi, Bing Lang and Mu Xiang are assistants in the formula. They help the chief and deputy herbs to activate the Qi movement in order to accelerate the water movement in the body.
• Qing Fen is used as assistant and envoy; it drains the water directly.
• When all the strong substances are used together, the water can be driven out from the body by bowel movement and urination, just like being carried by a vessel and vehicle, hence the name of this formula.
Commentary on strategies
• Since the chief herbs are very poisonous and the dosages should be kept to a minimum, a large amount of Qian Niu Zi is added as deputy, along with Da Huang. They enhance the abilities of the chief herbs and ensure the therapeutic result in a safe dosage range.
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| Figure 2.1 •. |
| Etiology and pathology of the syndrome of intestinal accumulation. |
